1801006161 CASE PRESENTATION

long case

A 50 year old male patient farmer by occupation came to the OPD with

CHIEF COMPLAINTS :

- shortness of breath since 13 days

- complaints of edema involving both lower limbs since 9 days

-Decreased urine output since 9 days

HISTORY OF PRESENTING ILLNESS:

Patient is apparently asymptomatic 13 days back then he developed

-Shortness of breath which was insidious in onset and gradually progressive and know it has been progressed to Grade 4 ,which is aggrevated on lying down and walking and relieved on sitting position.

- He also had developed bilateral pedal edema ,since 9 which is insidious in onset and pitting type in nature and which was initially Grade 1 and know it has been progressed to Grade4

-He also had decreased urine output since 9 days.

No history of chest pain,palpitations,syncope,fever, cough ,hemoptysis,burning micturition and knee pains.

PAST HISTORY:

He has an history of fall from tree 10 years back

He was also diagnosed with Tuberculosis and Diabetis mellitus 3 years back

He also noticed swelling in both legs and consulted a doctor and was diagnosed with Chronic kidney disease.

-Not a known case of ; Hypertension, thyroid, Asthma

TREATMENT HISTORY:

Drug history:

-uesd NSAIDS intermittently to relieve neck pain

-Antitubercular therapy (for tuberculosis)

- Metformin 500mg three times a day(for Diabetis mellitus)

Past surgical history:

No history of any surgeries in the past

PERSONAL HISTORY:-

-Patient takes mixed diet

-Appetite is normal

-Sleep is adequate

-Bowel - regular

-Bladder- urinary output was decreased from 9 days

-Addictions : Drinks alcohol occasionally

-Daily routine:

The patient was a farmer by occupation and wakes up at 6 am and has his breakfast at 7 am goes to work ,completes work by afternoon ,takes rest and has dinner at 8 pm ,sleep at 10pm

He is now staying now at home since the fall from tree due to low backache . He is not going to world anymore

FAMILY HISTORY:-

No significant family history

ALLERGIC HISTORY:-

No allergies to any kind of drugs or food items

GENERAL EXAMINATION:-

Patient is conscious, coherent, and cooperative well oriented to time place and person

Moderately built and nourished

No pallor

No icterus

No cyanosis

No clubbing

No lymphadenopathy

-Pitting edema seen in both lower limbs

VITALS:

Temperature - Afebrile

Pulse Rate - 102 bpm

Respiratory Rate - 15cpm

Blood Pressure - 150/90mmHg

Sp02 - 97% at Room air

GRBS - 203 mg/dl

SYSTEMIC EXAMINATION:

CVS EXAMINATION

INSPECTION:

Shape of chest is normal

Jugular venous pressure is mildly raised

No precardial bulge

Apex beat is not well appreciated

No dilated veins

PALPATION

Apex Beat - Shifted to 6th intercostal space lateral to mid clavicular line

No parasternal Heave

No thrills

PERCUSSION:

Left border of heart- Shifted laterally

Right border of heart is normal in location

AUSCULTATION:

S1 S2 Heard and no murmurs

RESPIRATORY SYSTEM

INSPECTION:

-Bilateral Air entry Present

-Trachea- central

- Movements of Chest decreased on left side

- Type of respiration- abdominothoracic

PALPATION:

-All inspectory findings confirmed by Palpation

- Expansion of chest decreased on left side.

-Tactile vocal fremitus

Right Left
Supra clavicular: normal normal
Infra clavicular: normal normal
Mammary: normal normal

Inframammary normal decreased

Axillary: normal normal
Infra axillary: normal decreased
Supra scapular: normal normal
Infra scapular: normal decreased
Inter scapular: normal normal

PERCUSSION:

RIGHT LEFT

Supra clavicular: resonant resonant
Infra clavicular: resonant resonant
Mammary: resonant resonant

Inframammary resonant resonant

Axillary: resonant resonant
Infra axillary: resonant dullnote
Supra scapular: resonant resonant
Infra scapular: resonant dullnote

Inter scapular: resonant resonant

AUSCULTATION:

- Vocal resonance

Right.                   Left

Supra clavicular:.       Normal Normal
Infra clavicular:          Normal Normal
Mammary: Normal Normal

Inframammary: Normal Normal
Axillary: Normal Normal
Infra axillary: Normal decreased
Supra scapular: Normal Normal
Infra scapular: Normal decreased
Inter scapular: Normal normal

Breath sounds

Right. Left

Supra clavicular:. Normal Normal
Infra clavicular: Normal Normal
Mammary: Normal Normal

Inframammary: Normal Normal
Axillary: Normal Normal
Infra axillary: Normal decreased

Supra scapular: Normal Normal
Infra scapular: Normal decreased
Inter scapular: Normal normal

Breath sounds

Right. Left

Supra clavicular:. Normal Normal
Infra clavicular: Normal Normal
Mammary: Normal Normal

Inframammary: Normal Normal
Axillary: Normal Normal
Infra axillary: Normal decreased
Supra scapular: Normal Normal
Infra scapular: Normal decreased

Inter scapular: Normal normal

ABDOMEN EXAMINATION:

INSPECTION

Abdomen Shape-Normal

Umbilicus is central in position

PALPATION -

No Tenderness on palpation.

Temperature - Afebrile

Liver is Non Tender

Spleen is Not palpable

PERCUSSION: tympanic note

AUSCULTATION Bowel Sounds Heard

CENTRAL NERVOUS SYSTEM :

Patient is conscious coherent and cooperative

Speech is normal

No signs of meningeal irritation

Cranial nerves - intact

Sensory system normal

Motor system:

Tone - normal

Power - bilaterally 5/5

Deep tendon reflexes

Biceps : ++

Triceps : ++

Supinator: ++

Knee : ++

Ankle : ++

Superficial reflexes - normal

Gait - normal

PROVISIONAL DIAGNOSIS:

Heart failure with left Pleural Effusion

INVESTIGATIONS:

CHEST XRAY

ECG

X ray skull

ULTRASOUND

USG CHEST

Free fluid noted in bilateral pleural spaces (left more than right) with underlying collapse

USG ABDOMEN

Raised Echogenicity of both kidneys

Hemogram:

Hemoglobin 11.7 gm/dl

Total count 9,000 cells/cumm

Neutrophils. 74

Lymphocytes 20

Eosinophils 2

Monocytes 4

Basophils 0

Pcv. 36.5 vol

Mcv. 82.8 fl

RDW- CV 19.1 %

RBC COUNT:. 4.4 million/cu/mm

LIVER FUNCTION TEST

Total Bilirubin - 0.9 mg/dl

Direct Bilirubin - 0.1 mg/dl

Indirect Bilirubin - 0.8 mg/dl

Alkaline Phosphatase - 221 u/l

AST - 40 u/l

ALT - 81 u/l

Protein Total - 6.8g/dl

Albumin - 4.2 g/dl

Globulin - 2.6 g/dl

Albumin:Globulin Ratio - 1.6

Renal Function Test

Urea - 64

Creatinine - 4.3

Na+ - 138

K+ - 3.4

Cl- - 104

Spot urine Protein - 34

Spot urine creatinine - 14.8

Spot Urine : Creatinine Ratio - 2.29

Fasting Blood Sugar - 93mg/dl

PLBS - 152 mg/dl

HbA1c - 6.5%

ABG :

pH : 7.3

pCO2 - 28.0

pO2 - 77.4

HCO3-.13.5

Spo2-94.7

DIAGNOSIS:

HEART FAILURE WITH reduced EJECTION FRACTION

AND BILATERAL PLEURAL EFFUSION

WITH ACUTE KIDNEY INJURY ON CHRONIC KIDNEY DISEASE (SECONDARY TO DIABETES/NSAID INDUCED)

WITH K/C/O DM II and TUBERCULOSIS SINCE 3 YEARS.

TREATMENT

1)Fluid Restriction less than 1.5 Lit/day

2) Salt restriction less than 1.2gm/day

3) INJ. Lasix 40mg IV / BD

4) TAB MET XL 25 mg

5) TAB. CINOD 5 MG PO/OD(IF SBP MORE THAN 110 MM HG)

6. INJ. HUMAN ACTRAPID INSULIN SC/TID (ACCORDING TO SLIDING SCALE)

7. INJ. PAN 40 MG IV/OD

8. INJ. ZOFER 4 MG IV/SOS

9. Vitals Monitoring

10 TAB. ECOSPRIN AV 75/10 MG PO/

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short case

40year old male who is a farmer by occupation and came to opd with

CHIEF COMPLAINTS;

loose stools yesterday 2 a.m

vomiting since today morning

HISTORY OF PRESENT ILLNESS;

Patient was apparently asymptomatic till yesterday evening then

he suddenly developed loose stools yesterday night @ 2 a.m 40 to 50 episodes of loose stools,large quantity, white coloured stools,foul smelling, non blood tinged

c/o vomiting 3 episodes in the morning, food particles as content,non projectile, non bilious, non foul smelling relieved on their own.for loose stools they went to local RMP and got symptomatic treatment

similar episodes of vomiting and loose stools 10 years back and got admitted for 1 week and discharged

H/O insecticides spray yesterday morning

No H/O outside food and water intake .No similar complaints to his family,neighbours

No h/o fever,cough,cold